Review Article
The Treatment of Mid‑shaft Clavicle Fractures Qing‑Hua Sang1, Zhi-Gang Gou2, Hua-Yong Zheng1, Jing‑Tao Yuan1, Jian‑Wen Zhao1, Hong‑Ying He1, Chuang Liu1, Zhi Liu1 2
1 Department of Orthopedics, Beijing Army General Hospital, Beijing 100700, China Department of Orthopedics, Tianjin Sanatorium Affiliated to Beijing Military Area Command, Tianjin 300381, China
Qing‑Hua Sang and Zhi-Gang Gou contributed equally to this work.
Abstract Objective: Through reviewing the relevant literature from the past decades, to summarize the assessment and management of fractures of the clavicle, and provide an overview of the clinical results of a range of treatment options. Data Sources: The data analyzed in this review are mainly from articles included in PubMed and EMBASE, published from 1960 to 2015. Study Selection: Studies involving assessment of fractures of the clavicle were reviewed. Further literatures were gathered regarding the conservative and surgical treatment of these fractures, including the methods of fixation and the surgical approaches used. Both conservative and surgical treatments were then compared and contrasted. Results: Through retrieving and reading the abstract, a total of 42 representative articles were selected, which covered all aspects of the conservative treatment and surgical treatment, and compared the advantages and disadvantages of different treatment options. Conclusions: Although the majority of recent data suggest that surgery may be more appropriate as it improves functional outcome and reduces the risk of complications, we recommend that the treatment should be individually assessed. Key words: Conservation; Internal Fixation; Intramedullary Fixation; Mid‑shaft Clavicle Fracture; Plate; Surgery
Introduction Fractures of the clavicle are common injuries, accounting for 2.6–4% of adult fractures and 35% of injuries to the shoulder girdle.[1] Mid‑shaft clavicle fractures are the most common, with an incidence of up to 82% of all clavicle fractures.[2] There has been an increase in the number of treatment options available and the frequency with which clavicle fractures are treated operatively. A number of technical challenges exist for the surgeon, and clinical results for a range of treatment methods have been variable. There is still controversy about the choice of treatment, which patients are suitable for conservative treatment and whether the clinical outcomes can be improved by surgery, and how to choose the approach and implants during surgery. Here we summarize the assessment and management of fractures of the clavicle, providing an overview of the clinical results achieved using a range of treatment options.
Surgery and Conservative Treatment Acute clavicle fractures were traditionally treated nonoperatively. This treatment strategy reportedly achieved high union rate, good functional recovery, and high patient‑related satisfaction; Access this article online Quick Response Code:
Address for correspondence: Prof. Zhi Liu, Department of Orthopedics, Beijing Army General Hospital, Beijing 100700, China E‑Mail: [email protected] This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact: [email protected]
Website: www.cmj.org
DOI: 10.4103/0366-6999.168068
2946
Neer[3] reported low nonunion rates after nonoperative treatment of mid‑shaft clavicle fracture of 0.1%. Although nonoperative treatment was the major treatment strategy used for a long time, recent studies have identified higher rates of nonunion. In addition, patients treated nonoperatively are at high risk of clinical symptoms such as pain, loss of strength, and rapid fatigability associated with nonunion and malunion of clavicle fractures.[4] Thus, outcomes following nonoperative treatment are being increasingly doubted by researchers.[5] The available literature reports nonunion rates of up to 15% when nonoperative treatment was used for displaced mid‑shaft clavicle fractures.[6] However, this does not mean that surgery is definitely better than conservative treatment; it is still not confirmed whether all adult displaced mid‑shaft clavicle fractures should be treated by operative fixation.[7]
© 2015 Chinese Medical Journal ¦ Produced by Wolters Kluwer ‑ Medknow
Received: 17‑07‑2015 Edited by: Peng Lyu How to cite this article: Sang QH, Gou ZG, Zheng HY, Yuan JT, Zhao JW, He HY, Liu C, Liu Z. The Treatment of Mid-shaft Clavicle Fractures. Chin Med J 2015;128:2946-51. Chinese Medical Journal ¦ November 5, 2015 ¦ Volume 128 ¦ Issue 21
Surgical treatment of mid‑shaft clavicle fracture is most commonly done using plates and intramedullary devices; studies have reported significant advantages using these surgical methods compared with nonoperative treatment.[8] Although open reduction with internal fixation (ORIF) was associated with a lower rate of malunion and nonunion, shorter time to union, and better functional recovery, the results from a multicenter trial showed that operative treatment had a complication rate of 34% and a reoperation rate of 18%.[9] A report of Timothy et al. at the 2014 American Academy Orthopedic Surgeon, analyzed 1,350 patients aged 16–60 years who were treated with internal fixation from 2002 to 2010, and found that the reoperation rate reached up to 25%. A multicenter trial, initiated by Robinson et al., [10] comparing surgery with conservative treatment of fresh displaced mid‑shaft clavicle fracture, suggest that conservative treatment should be the first choice for most patients, and ORIF is highly recommended for patients aged 16–30 years. A mean follow‑up of 5 years, reported by van der Ven Denise et al.[11] comparing with conservation, significant superior outcome scores were seen at 6 weeks for the operative group, However, at 24-week and 5‑year follow‑up no difference was seen in functional outcome scores for both treatment groups. The only drawback of nonoperative treatment is the higher rate of nonunion compared with surgery.[12] Hence, surgical treatment should be chosen for those with a high risk of fracture nonunion, while patients with lower risk of fracture nonunion can be treated conservatively. High risk factors for fracture nonunion are comminuted fracture, displaced fracture, and smoking. In addition, Hill et al.[13] found that the rate of fracture nonunion was significantly increased if the initial fracture fragments were
The Treatment of Mid‑shaft Clavicle Fractures Qing‑Hua Sang1, Zhi-Gang Gou2, Hua-Yong Zheng1, Jing‑Tao Yuan1, Jian‑Wen Zhao1, Hong‑Ying He1, Chuang Liu1, Zhi Liu1 2
1 Department of Orthopedics, Beijing Army General Hospital, Beijing 100700, China Department of Orthopedics, Tianjin Sanatorium Affiliated to Beijing Military Area Command, Tianjin 300381, China
Qing‑Hua Sang and Zhi-Gang Gou contributed equally to this work.
Abstract Objective: Through reviewing the relevant literature from the past decades, to summarize the assessment and management of fractures of the clavicle, and provide an overview of the clinical results of a range of treatment options. Data Sources: The data analyzed in this review are mainly from articles included in PubMed and EMBASE, published from 1960 to 2015. Study Selection: Studies involving assessment of fractures of the clavicle were reviewed. Further literatures were gathered regarding the conservative and surgical treatment of these fractures, including the methods of fixation and the surgical approaches used. Both conservative and surgical treatments were then compared and contrasted. Results: Through retrieving and reading the abstract, a total of 42 representative articles were selected, which covered all aspects of the conservative treatment and surgical treatment, and compared the advantages and disadvantages of different treatment options. Conclusions: Although the majority of recent data suggest that surgery may be more appropriate as it improves functional outcome and reduces the risk of complications, we recommend that the treatment should be individually assessed. Key words: Conservation; Internal Fixation; Intramedullary Fixation; Mid‑shaft Clavicle Fracture; Plate; Surgery
Introduction Fractures of the clavicle are common injuries, accounting for 2.6–4% of adult fractures and 35% of injuries to the shoulder girdle.[1] Mid‑shaft clavicle fractures are the most common, with an incidence of up to 82% of all clavicle fractures.[2] There has been an increase in the number of treatment options available and the frequency with which clavicle fractures are treated operatively. A number of technical challenges exist for the surgeon, and clinical results for a range of treatment methods have been variable. There is still controversy about the choice of treatment, which patients are suitable for conservative treatment and whether the clinical outcomes can be improved by surgery, and how to choose the approach and implants during surgery. Here we summarize the assessment and management of fractures of the clavicle, providing an overview of the clinical results achieved using a range of treatment options.
Surgery and Conservative Treatment Acute clavicle fractures were traditionally treated nonoperatively. This treatment strategy reportedly achieved high union rate, good functional recovery, and high patient‑related satisfaction; Access this article online Quick Response Code:
Address for correspondence: Prof. Zhi Liu, Department of Orthopedics, Beijing Army General Hospital, Beijing 100700, China E‑Mail: [email protected] This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact: [email protected]
Website: www.cmj.org
DOI: 10.4103/0366-6999.168068
2946
Neer[3] reported low nonunion rates after nonoperative treatment of mid‑shaft clavicle fracture of 0.1%. Although nonoperative treatment was the major treatment strategy used for a long time, recent studies have identified higher rates of nonunion. In addition, patients treated nonoperatively are at high risk of clinical symptoms such as pain, loss of strength, and rapid fatigability associated with nonunion and malunion of clavicle fractures.[4] Thus, outcomes following nonoperative treatment are being increasingly doubted by researchers.[5] The available literature reports nonunion rates of up to 15% when nonoperative treatment was used for displaced mid‑shaft clavicle fractures.[6] However, this does not mean that surgery is definitely better than conservative treatment; it is still not confirmed whether all adult displaced mid‑shaft clavicle fractures should be treated by operative fixation.[7]
© 2015 Chinese Medical Journal ¦ Produced by Wolters Kluwer ‑ Medknow
Received: 17‑07‑2015 Edited by: Peng Lyu How to cite this article: Sang QH, Gou ZG, Zheng HY, Yuan JT, Zhao JW, He HY, Liu C, Liu Z. The Treatment of Mid-shaft Clavicle Fractures. Chin Med J 2015;128:2946-51. Chinese Medical Journal ¦ November 5, 2015 ¦ Volume 128 ¦ Issue 21
Surgical treatment of mid‑shaft clavicle fracture is most commonly done using plates and intramedullary devices; studies have reported significant advantages using these surgical methods compared with nonoperative treatment.[8] Although open reduction with internal fixation (ORIF) was associated with a lower rate of malunion and nonunion, shorter time to union, and better functional recovery, the results from a multicenter trial showed that operative treatment had a complication rate of 34% and a reoperation rate of 18%.[9] A report of Timothy et al. at the 2014 American Academy Orthopedic Surgeon, analyzed 1,350 patients aged 16–60 years who were treated with internal fixation from 2002 to 2010, and found that the reoperation rate reached up to 25%. A multicenter trial, initiated by Robinson et al., [10] comparing surgery with conservative treatment of fresh displaced mid‑shaft clavicle fracture, suggest that conservative treatment should be the first choice for most patients, and ORIF is highly recommended for patients aged 16–30 years. A mean follow‑up of 5 years, reported by van der Ven Denise et al.[11] comparing with conservation, significant superior outcome scores were seen at 6 weeks for the operative group, However, at 24-week and 5‑year follow‑up no difference was seen in functional outcome scores for both treatment groups. The only drawback of nonoperative treatment is the higher rate of nonunion compared with surgery.[12] Hence, surgical treatment should be chosen for those with a high risk of fracture nonunion, while patients with lower risk of fracture nonunion can be treated conservatively. High risk factors for fracture nonunion are comminuted fracture, displaced fracture, and smoking. In addition, Hill et al.[13] found that the rate of fracture nonunion was significantly increased if the initial fracture fragments were
